植入药物洗脱支架后出现的晚期支架血栓和自我栓病例

A case of very late stent thrombosis and self-thrombolysis after implantation of drug eluting stent阜外心血管病医院阜外心血管病医院 李崇剑李崇剑 杨跃进杨跃进Case informationnMale, 49y.nHT (-), DM (-), Dyslipidemia (-), Smoker (-), FH (-)nAMI (anterior wall) in sep. 2004.nEmergency CAG: ostial LAD 100%, ostial LCX 60%, normal RCA.nEmergency PCI: Cypher in LAD. Detail not acquired.nDrug: (Plavix 75mg/d+ASA 100mg/d)*1y, followed by ASA 75mg/d*qod, other cardio drugs routinely.Case information follow upnAcute chest pain, Re-AMI (anterior) in 6, Nov. 2007.nEmergency CAG: cloud in stent, defect of mid-distal stent, TIMI grade 0. LCX the same as before, normal RCA.nCABG or PCI not performed.nFollowed by drugs: (Plavix 300mg/d+ASA 100mg/d+LWMH 1mg/kg q12h)*12d, other cardio drugs routinely.Angiograhpy (6, Nov. 2007): LAD and LCXAngiograhpy (6, Nov. 2007): RCAFollow up: 2 weeks laternCAG after 2 weeks: no throbosis in stent, LAD TIMI 3. LCX the same as before, normal RCA.Angiography follow upDiscussionThrombosis of DESnDefinitionnThe mechanismnStrategy今今天天讨讨论论重重点点DES preventing restenosis after PCIStent: Vessel Recoil and RemodellingDrug:Intimal ProliferationDilemma of safety: thrombosisARC Definition of STnAcute 0-24hnSubacute 24h-30d nLate 30d-1ynVery late after 1ynDefinite/confirmednProbablenPossibleTime courseAngiography and clinical evidence298.75.53.53.22.61.305101520253035*Antiplatelet Therapy discPrior Brachy Renal failureBifurcations ULMDiabetesUAThrombosis rates according to selected patient characteristics%* Premature discontinuationFrom A. Colombo, MDClinical predictors of stent thrombosis0.01 0.1 1 10 100 0.01 0.1 1 10 100 No thieno* (0-6m)No thieno* (6-18m)LVEF* 30%Prior BrachytherapyRVD*Final atmStent LengthHR=11.7; 95%CI, 3.47-39.24, p0.0001HR=1.01; 95%CI, 0.30-3.46, p=0.98HR=4.32; 95%CI, 1.61-11.60, p=0.004HR=9.89; 95%CI, 3.56-27.46,p0.0001 HR=0.16; 95%CI, 0.03-0.82, p=0.03HR=0.41; 95%CI, 0.18-0.92, p=0.03HR=3.41; 95%CI, 1.94-5.97, p0.0001From A. Colombo, MDDES delayed healing: delayed endothelializationCypherTaxusEFHI500 m2 mm500 m200 m500 m200 m500 mC2 mm200 mJ200 mABxVelocity2 mmBDExpressLK2 mmGA. Finn, Renu Virmanin, SOLACI 2006DES: not only suppress SMC infiltration but also delay endothelialization, leading to stent thrombosisPolymer in DES: localized hypersensitivityVirmani, R. et al. Circulation 2004;109:701-705Late malapposition基线正性管腔重构没有管腔重构随访随访在在Taxus和和Cypher的研究中的研究中，发发生晚生晚期期贴贴壁不良的患者停止壁不良的患者停止clopidogrel治治疗疗后后20% 发生了支架血栓发生了支架血栓*！* Study by Dr. Abizaid, presented at TCT 2005.M, 44y, Cypher due to prior AMI, Clopidegrel was discontinued after 3m, aspirin 150mg/d was continued. 31m later, thrombosis.Eur Heart J. 21 Oct 2005.Case due to late malappositionDiscussion: othersnManufacturing & DeliverabilitynHigh pressure, side branch dilatationnInhomogenous drug deliverynThrombogenicitynRestenosis is delayed and but not eliminatednAnd so on.Discussion: strategyn重要的是重要的是对对LaSTLaST形成的研究现状要有清晰的认识，针对可能的发生机制形成的研究现状要有清晰的认识，针对可能的发生机制采取综合措施；采取综合措施；n该患者年仅该患者年仅4949岁，岁，DESDES术后坚持术后坚持1 1年的双重抗血小板治疗，年的双重抗血小板治疗，中止氯吡咯雷中止氯吡咯雷2626个月后个月后出现出现LaSTLaST，无合并糖尿病、肾功能不全等病史，虽然未评价血，无合并糖尿病、肾功能不全等病史，虽然未评价血小板功能，但是推测血栓的形成可能与中止抗血小板治疗及小板功能，但是推测血栓的形成可能与中止抗血小板治疗及LADLAD支架操支架操作有关，也很可能是血管对作有关，也很可能是血管对DESDES的迟发反应。大多数专家认为双重抗血的迟发反应。大多数专家认为双重抗血小板最少要小板最少要12个月个月，至于是否需要更进一步延长还未达成共识，需要更，至于是否需要更进一步延长还未达成共识，需要更多的循证医学证据来根据晚期血栓事件的风险对患者进行分层。多的循证医学证据来根据晚期血栓事件的风险对患者进行分层。n本患者在本患者在DESDES术后术后3838个月发生靶血管个月发生靶血管AMIAMI，造影提示支架内血栓形成的特，造影提示支架内血栓形成的特点，其临床过程表现为血栓自溶、血管再通，但是，缺乏血管内超声检点，其临床过程表现为血栓自溶、血管再通，但是，缺乏血管内超声检查：查：再狭窄、内皮、血栓、重构再狭窄、内皮、血栓、重构。 n该患者幸免于第二次植入支架，是否意味着该患者幸免于第二次植入支架，是否意味着DES心肌梗死患者如果错过心肌梗死患者如果错过了急诊介入时机，造影显示血栓负荷较重者可以先了急诊介入时机，造影显示血栓负荷较重者可以先强化抗栓治疗强化抗栓治疗一段时一段时间后再决定是否介入治疗，这种情况下的抗血小板、抗凝治疗方案、治间后再决定是否介入治疗，这种情况下的抗血小板、抗凝治疗方案、治疗时间长短均有待进一步研究。疗时间长短均有待进一步研究。n最强有力的最强有力的GPb/aGPb/a受体拮抗剂受体拮抗剂在在DESDES晚期血栓形成治疗中的效果以及晚期血栓形成治疗中的效果以及对心功能的改善作用？对心功能的改善作用？